Individual Enrollment
Plan Information
Plan Selection
*
Basic MEC
Ultimate MEC
Basic MEC
Single
Single + Spouse
Single + Child(ren)
Family
Ultimate MEC
Single
Single + Spouse
Single + Child(ren)
Family
Plan Start Date
Your coverage will start on the 1st of the month.
Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Year
*
2020
2021
Primary Member Information
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Social Security Number
*
Date of Birth
*
Date Format: MM slash DD slash YYYY
Gender
*
Male
Female
Email
*
How did you hear about us?
*
IPSSA
Other
Dependent 1 Information
Name
*
First
Last
Social Security Number
*
Date of Birth
*
Date Format: MM slash DD slash YYYY
Gender
*
Male
Female
Relationship
*
Spouse
Child
Domestic Partner
Step-Child
Add Another Dependent?
Yes
Dependent 2 Information
Name
*
First
Last
Social Security Number
*
Date of Birth
*
Date Format: MM slash DD slash YYYY
Gender
*
Male
Female
Relationship
*
Spouse
Child
Domestic Partner
Step-Child
Add Another Dependent?
Yes
Dependent 3 Information
Name
*
First
Last
Social Security Number
*
Date of Birth
*
Date Format: MM slash DD slash YYYY
Gender
*
Male
Female
Relationship
*
Spouse
Child
Domestic Partner
Step-Child
Add Another Dependent?
*
Yes
No
Dependent 4 Information
Name
*
First
Last
Social Security Number
*
Date of Birth
*
Date Format: MM slash DD slash YYYY
Gender
*
Male
Female
Relationship
*
Spouse
Child
Domestic Partner
Step-Child
Add Another Dependent?
*
Yes
No
Dependent 5 Information
Name
*
First
Last
Social Security Number
*
Date of Birth
*
Date Format: MM slash DD slash YYYY
Gender
*
Male
Female
Relationship
*
Spouse
Child
Domestic Partner
Step-Child
Billing Information
Payment will be drafted on or around the 10th of every month.
Name on Account
*
Billing Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Account Type
*
Checking
Savings
Routing Number
*
Account Number
*